GP - Diabetes Flashcards
What interpreter services might a GP practice utilise?
- If patient’s book in advance and the practice knows of the need for an interpreter then one can be booked to visit the practice at the time of the appointment
- If the appointment is made in less than 24-48hrs then a telephone interpreter service is often used (not as good as lacks interpreter body language)
Why might using a family member as an interpreter during a patient consultation not be a good idea?
- Confidentiality issues
- Pt may be reluctant to discuss some issues with family present
- Family member have ulterior motives and thus control the conversation
- Family member not understanding medical terms and therefore translating wrongly
- Poor interpreter skills - translation from one language to another is a difficult skill
- Consultations may last longer than normal due to needing to repeat questions multiple times
What are some common side-effects of metformin?
- Abdominal pain
- Nausea
- Anorexia
- Diarrhoea (usually transient)
- Taste disturbances
- Vomiting
A rare side effect of metformin can result in macrocytic anaemia.
How can this occur?
Rarely, metformin can reduce B12 absorption
This can result in B12 deficient anaemia which is macrocytic
What medications can be used to manage T2DM?
-
Metformin
- ↓ liver glucose production (gluconeogenesis), ↓ weight, ↑ insulin sensitivity
-
Sulphonylureas
- e.g. gliclazide, glipizide, glimepiride and glibenclamide
- ↑ insulin secretion via stimualting pancreatic ß-cells
-
Thiazolidinediones (glitazones)
- e.g. Pioglitazone or rosiglitazone
- Stim nuclear receptor PPAR-gamma (perioxisome proliferator-activated receptor gamma) –> this causes gene modulation resulting in; ↑ storage of fatty acids in adipocytes (adipogenesis) - thus ↓ fatty acids in circulation, making the body depend on carbohydrates more (e.g. glucose)
- ↓ insulin resistance, ↓ liver gluconeogenesis, ↑ adipogenesis
-
Gliptins
- e.g. sitagliptin, vildagliptin, linagliptin and alogliptin
- Are DPP4-inhibitors
- DPP4 breaks down GLP-1 (glucagon like peptide-1) - which is an incretin (↓ plasma glucose via ↑ insulin section and ↓ glucagon secretion)
-
SGLT-2 inhibitors (-gliflozins)
- e.g. dapagliflozin, canagliflozin, empagliflozin
- Inhibit glucose reabsorption in kidney
-
GLP-1 receptors agonists (-tides)
- e.g. exanatide or liraglutide
- Mimic GLP-1 –> ↓ plasma glucose via ↑ insulin section and ↓ glucagon secretion
In what order are the pharmacological treatments for T2DM escalated?
- Metformin
- Sulphonylureas
- Gliptins
- Pioglitazone
- SGLT-2 inhibitors
- GLP-1 agonists
What are the side-effects of the following drugs:
- Insulin
- Metformin
- Sulfonylureas
- Thiazolidinediones (pioglitazone)
- Gliptins
- SGLT-2 inhibitors
- GLP-1 agonists
Insulin
- Hypoglycaemia
- Weight gain
- Lipohypertrophy - small lump under skin due to fat accumulation at injection sites (insulin causes fat hypertrophy)
Metformin
- Abdominal pain
- Nausea
- Flatulence
- Anorexia
- Diarrhoea (usually transient)
- Taste disturbances
- Vomiting
- Lactic acidosis
Sulfonylureas
- Hypoglycaemia
- Weight gain / ↑ appetite
- Jaundice (is hepatically cleared so jaundice can occur in hepatic impairment)
- Chlorpropamide - can ↑ ADH –> hyponatraemia
Thiazolidinediones (pioglitazone)
- Weight gain
- Fluid retention
- Fractures (2 x risk in women, but not men)
Gliptins
- ↑ risk of pancreatitis
SGLT-2 inhibitors
- UTIs
GLP-1 agonists
- Nausea / vomiting
- Pancreatitis
If metformin is contraindicated or not tolerated - outline the management algorithm for T2DM in an adult.
What criteria can qualify a patient for free NHS prescriptions?
- > 60-yrs old
- < 16-yrs old
- 16-18 + in full-time education
- pregnant OR given birth in previous 12 months + have a valid maternity exemption certificate (MatEx)
- have a valid medical exemption certificate (MedEx) - given for specific conditions
- valid MedEx + continuing physical disability that prevents you from going out without aid of another person
- valid war pension exemption certificate + prescription is for your accepted disability
- are an NHS inpatient
Give some examples of scenarios / conditions that medical exemption certificates (MedEx) are given for?
- Permanent fistula (e.g. aecostomy, colostomy, laryngostomy or ileostomy) requiring continuous surgical dressing or an appliance
- Hypoadrenalism (e.g. Addison’s disease) + require substitution therapy
- Diabetes insipidus or other hypopituitarism
- Diabetes mellitus (unless controlled with diet only)
- Hypoparathyroidism
- Myathenia Gravis
- Myoedema (hypothyroidism requiring thyroid replacement)
- Epilepsy - needing continuous AEDs
- Continuing physical disability which means the person cannot go out without aid of another person
- Cancer treatment - including for effects of cancer, or effects of prior cancer treatment
What are the DVLA regulations regarding diabetes mellitus for pts driving the following:
1) Cars
2) HGVs
Cars:
- If on Insulin, pt can drive a car if:
- They have hypoglycaemic awareness
- No more than 1 episode of hypoglycaemia requiring assistance of another person in the last 12 months
- No relevant visual impairement
- Drivers are normally contacted by DVLA
- If on drugs that can cause hypos (e.g. sulphonylureas):
- No more than 1 episode of hypoglycaemia requiring assistance of another person in the last 12 months
- If diet controlled:
- No need to inform DVLA
HGV:
If on Insulin or other hypo causing medication (e.g. sulphonylureas);
- Must not have had any severe hypoglycaemic event (requiring assistance) in the previous 12 months
- The driver has full hypoglycaemic awareness
- The driver must show adequate glucose control via regular blood glucose monitoring (at least twice daily and at times relevant to driving)
- The driver must demonstrate an understanding of the risks of hypoglycaemia
- There are no other debarring complications of diabetes
Which diabetes mellitus medications run the risk of causing hypoglycaemia?
Sulphonylureas e.g. gliclazide
and
Insulin
Gliptins e.g. sitagliptin are excreted via what route?
Gliptins in general have a renal excretion profile
thus need to be careful if eGFR is low
Which Gliptin is the exception in that is isn’t predominantly renally excreted?
Linagliptin
Which is excreted via bile + gut
Which diabetes mellitus medication should be avoiding in pts with heart failure or Hx of heart failure?
Pioglitazone
